Join Our Team | Carolina Behavioral Innovations, LLC

Join Our Team — Application for Employment

Carolina Behavioral Innovations, LLC. Please complete this application. Fields marked with * are required.

Position Desired

Position Applied For*

Seeking*

Full Time

Part Time

Temporary / Substitute

Full-time employment is 40 hours per week, with availability to work between 8:00 AM and 6:00 PM.

Days & Hours Available For Work

If applying for part time, please list the days and hours you are available.

Date You Can Begin Work*

Rate of Pay

Enter your requested rate of pay.

Salary or Hourly

RBT Experience & Certification

Have you ever worked as an RBT for another company?*

Yes

Do you have an active RBT certificate?*

Yes

If yes, when does your RBT certificate expire?

Employment History With Us

Have you filed an application with us before?*

Yes

If yes, when and for what position?

Have you ever worked for the company before?*

Yes

If yes, what location & in what capacity?

Dates of employment

Personal Information

Name*

First Middle Last

Gender*

Male

Female

Non-binary

Prefer not to answer

Gender Assigned at Birth*

Male

Female

Prefer not to answer

Home Address

Street Address Address Line 2 City State ZIP Code

Telephone Number*

Alternate Number

Email Address*

Are you authorized to work in the United States?*

Yes

Are you at least 18 years of age?*

Yes

Do you have a high school diploma or equivalent?*

Yes

How were you referred to us?

Do you have friends or relatives working for us?*

Yes

If yes, list name(s), relationship & where employed

General Information

Have you ever been convicted of or pled guilty to a felony or misdemeanor, or are you currently under pending investigation or charges? **

Yes

*A conviction record will not necessarily be a bar to employment. Do not include information concerning convictions that have been dismissed, expunged or sealed.

If yes, please explain and state charge(s), court, date and disposition of case(s) for each violation

Have you ever been accused in a civil matter or a defendant in a lawsuit involving negligence, neglect or abuse (e.g. physical/sexual) with regard to a person in your care?*

Yes

If yes, please explain in detail

Do you have a valid driver license? ***

Yes

**Absence of a driver license is not a bar to employment, except in positions that may require driving as an essential function of the job.

If no, can you acquire a driver license if required?

Yes

Are you restricted, or do you have a previous or related injury, that would impact your ability to bend, kneel, or lift on a regular basis?*

Yes

If yes, please explain

Have you ever been disciplined, fired or asked to resign from a job because of negligence, neglect, abuse (e.g. physical/sexual), or any violation of an employer's policy and procedures?*

Yes

If yes, please explain

Have you ever been discharged or asked to resign in lieu of discharge for any other reason (excluding lay-off)?*

Yes

If yes, please explain

Employment History

List present (or most recent) employer first. Include any military or volunteer experience, if applicable. We only need 5 years of total work history, if applicable.

May we contact your present employer?*

Yes

Employer #1 (most recent)

Employer #1 — Name & Address of Employer*

Employer #1 — Supervisor Name and Title

Employer #1 — Email of Employer/Supervisor

Employer #1 — Phone Number

Employer #1 — Position*

Employer #1 — From (MM/YY)*

Employer #1 — To (MM/YY)

Employer #1 — Last Salary

Employer #1 — Describe your principal duties and responsibilities

Employer #1 — Reason for leaving (if quit, state why; if terminated, what reason was given to you?)

Employer #2 (if applicable)

Employer #2 — Name & Address of Employer

Employer #2 — Supervisor Name and Title

Employer #2 — Email of Employer/Supervisor

Employer #2 — Phone Number

Employer #2 — Position

Employer #2 — From (MM/YY)

Employer #2 — To (MM/YY)

Employer #2 — Last Salary

Employer #2 — Describe your principal duties and responsibilities

Employer #2 — Reason for leaving (if quit, state why; if terminated, what reason was given to you?)

Employer #3 (if applicable)

Employer #3 — Name & Address of Employer

Employer #3 — Supervisor Name and Title

Employer #3 — Email of Employer/Supervisor

Employer #3 — Phone Number

Employer #3 — Position

Employer #3 — From (MM/YY)

Employer #3 — To (MM/YY)

Employer #3 — Last Salary

Employer #3 — Describe your principal duties and responsibilities

Employer #3 — Reason for leaving (if quit, state why; if terminated, what reason was given to you?)

Employer #4 (if applicable)

Employer #4 — Name & Address of Employer

Employer #4 — Supervisor Name and Title

Employer #4 — Email of Employer/Supervisor

Employer #4 — Phone Number

Employer #4 — Position

Employer #4 — From (MM/YY)

Employer #4 — To (MM/YY)

Employer #4 — Last Salary

Employer #4 — Describe your principal duties and responsibilities

Employer #4 — Reason for leaving (if quit, state why; if terminated, what reason was given to you?)

Education

High School

High School — Name and Location of School

High School — Number of Years Attended

High School — Graduated?

Yes

College

College — Name and Location of School

College — Number of Years Attended

College — Graduated?

Yes

College — Degree / Course of Study

Post Graduate

Post Graduate — Name and Location of School

Post Graduate — Number of Years Attended

Post Graduate — Graduated?

Yes

Post Graduate — Degree / Course of Study

Other

Other — Name and Location of School

Other — Number of Years Attended

Other — Graduated?

Yes

Other — Degree / Course of Study

Are you presently enrolled in any courses?

Yes

If yes, where? List courses

Professional References

People you have worked with or for. Please do not list relatives.

Reference #1

Reference #1 — Name*

Reference #1 — Job Title

Reference #1 — Company

Reference #1 — Email Address*

Reference #1 — Phone Number*

Reference #2

Reference #2 — Name*

Reference #2 — Job Title

Reference #2 — Company

Reference #2 — Email Address*

Reference #2 — Phone Number*

Reference #3

Reference #3 — Name*

Reference #3 — Job Title

Reference #3 — Company

Reference #3 — Email Address*

Reference #3 — Phone Number*

Licensure, Credential and Certification

List all local and out-of-state certifications and/or credentials now held. This section is optional.

Credential #1

Credential #1 — Type of License, Credential or Certification

Credential #1 — Issuing State or Organization

Credential #1 — License Number

Credential #1 — Date Issued

Credential #1 — Expiration Date

Credential #2

Credential #2 — Type of License, Credential or Certification

Credential #2 — Issuing State or Organization

Credential #2 — License Number

Credential #2 — Date Issued

Credential #2 — Expiration Date

Credential #3

Credential #3 — Type of License, Credential or Certification

Credential #3 — Issuing State or Organization

Credential #3 — License Number

Credential #3 — Date Issued

Credential #3 — Expiration Date

Credential #4

Credential #4 — Type of License, Credential or Certification

Credential #4 — Issuing State or Organization

Credential #4 — License Number

Credential #4 — Date Issued

Credential #4 — Expiration Date

Has your credential, license or certification ever been suspended or revoked?

Yes

Not Applicable

If yes, please explain

Have you ever been sanctioned, disciplined, debarred, and/or excluded by a duly authorized agency, or are there any current restrictions or limits on your license(s) or certification(s)?

Yes

Not Applicable

If yes, please explain

If you have no credential, license or certification now, have you applied for one?

Yes

Not Applicable

If applied — State

If applied — Date Applied

If applied — Type

Additional Information

Are there any special skills or qualifications which you feel would qualify you for this position?

Do you speak, read or write in any language other than English?

Yes

If yes, which language(s)?

Uploads

Driver License — Upload*

Max. file size: 32 MB.

Mandatory. Upload your driver license. All file formats accepted.

Certificates — Upload

Drop files here or

Max. file size: 32 MB, Max. files: 10.

Optional. Upload any relevant certificates (RBT, BCBA/BCaBA, CPR, etc.).

Authorizations & Conditions

Please read carefully before signing.

CONDITIONS OF APPLICATION AND EMPLOYMENT — PLEASE READ CAREFULLY BEFORE SIGNING

I hereby certify that the information contained in this application, or made in conjunction with it, is true and correct, and any misrepresentation or omission of any detail will be grounds for disqualification from employment or dismissal should I be employed, whenever the correct information becomes known to the Company.

I understand that this application for employment does not in any way constitute an offer of employment or a contract of employment. Employment with the Company is not by contract expressed or implied. Furthermore, should I be employed, I understand that my employment is for no definite duration but on an ‘at-will’ basis. No representative of the Company has the authority to make any assurance to the contrary except the President of the Company.

Signature

Applicant Signature*

Date*